Medicare Claims Auditor I - Quality & Compliance

Solis-Health-Plans; Florida; On-site; USD 68,161,000 - 102,009,000; Full time

Job summary

Solis-Health-Plans in Doral, FL is seeking a Claims Auditor I to perform pre- and post-payment audits of Medicare-related claims within a managed care environment. The role emphasizes payment accuracy, CMS guidelines, and compliance.

You will review CPT/HCPCS/ICD coding, pricing and reimbursement methods, and collaborate with claim examiners to identify discrepancies and improve processes. Minimum qualifications include a high school diploma and several years of claims processing experience;

Qualifications

• High School Diploma or GED required.
• Minimum of 5 years of claims processing experience, preferably within healthcare or insurance.
• At least 1 year of experience in a quality audit or claims auditing role.
• Experience with Medicare (CMS) guidelines and managed care environments strongly preferred.
• Equivalent combination of education and experience may be considered.

Responsibilities

• Perform pre- and post-payment audits of claims, including high-dollar and complex claims, across Medicare managed care lines of business.
• Audit work completed by claim examiners and associates to ensure accuracy in underpayment dispute processing.
• Validate claim payment accuracy by reviewing: CPT, HCPCS, ICD.
• Analyze pricing and reimbursement methodologies and authorization requirements.
• Assess medical necessity in accordance with CMS guidelines.
• Ensure adherence to internal policies, CMS Medicare regulations, and clinical guidelines.
• Independently interpret medical policies, regulatory requirements, and reimbursement guidelines.
• Maintain acceptable audit inventory levels and turnaround times.
• Produce audit reports used for trend analysis and compliance reporting.
• Track and trend audit outcomes to identify systemic issues and opportunities for improvement.

Skills

Medical terminology

Claims processing

Coding methodologies

Audit techniques

Analytical skills

Attention to detail

Communication skills

Education

High school diploma or GED

Job description

Solis-Health-Plans in Doral, FL is seeking a Claims Auditor I to perform pre- and post-payment audits of Medicare-related claims within a managed care environment. The role emphasizes payment accuracy, CMS guidelines, and compliance.

You will review CPT/HCPCS/ICD coding, pricing and reimbursement methods, and collaborate with claim examiners to identify discrepancies and improve processes. Minimum qualifications include a high school diploma and several years of claims processing experience;